I recently finished the audiobook version of John Adams, David McCullough’s masterwork biography of the second President. Listening to Edward Hermann’s narration completed my third tour through the adventure of John Adams’ life. I had already read the book, then viewed the HBO miniseries starring Paul Giamatti and Laura Linney.

The book is of course the most complete version, as editorial decisions needed to be made for the miniseries. Although a few historical changes were made, the miniseries brings the era to life in vivid detail.

I have a particular interest in the medical elements of the story. Let’s take a look at three of them:

SmallpoxOne scene depicts an early form of smallpox vaccination. Technically speaking this is variolation – the inoculation from a smallpox pustule into a small cut on the individual being immunized. Given the 30% mortality rate of smallpox, the 1-2% chance of death from the variolation procedure seemed an acceptable risk. This would remain the procedure of choice until Edward Jenner popularized inoculation with cowpox, which carried a far lower chance of death while still achieving immunity from smallpox. Smallpox was eradicated in the 20th century, now found only in laboratories in the U.S. and Russia. The debate today concerns whether the remaining smallpox should be preserved or destroyed.

Breast Cancer

Image via Wikipedia

Another interesting and harrowing scene features Adams’ daughter Nabby, who was diagnosed with breast cancer, and underwent a mastectomy. In the early 19th century the only possible cure was “the knife”, as Benjamin Rush told Adams. It is likely that anyone cured in that era likely had a diagnosis other than invasive adenocarcinoma, or had a very small tumor. We know today that breast cancer is treated both as a systemic disease as well as a local one. Nabby’s mastectomy allowed for local control, though it probably wasn’t worth the suffering she endured in that awful pre-anesthetic era of surgery. It struck me as unlikely that her longevity was improved by undergoing the operation.

Longevity
A final consideration is John Adams’ long life, which extended into his 91st year. It seems apparent that good genes and good luck were as important to a long life then as they are now. His smallpox variolation was helpful in avoiding contracting that scourge. It is also noted that Adams badly cut his leg “to the bone” in a fall after retiring to his farm. His healing of this wound is another testament to a hardy constitution. Through most of his life, he drank hard cider, smoked a pipe, and carried a decent amount of weight. Compared to 21st century medicine, most forms of medical intervention in Adams’ day were worthless at best and often harmful. Good genes and good luck go a long way in any century.

Lehman’s story is not over, as the bankruptcy is not yet complete. Speculation continues to revolve around whether or not any senior executives will be criminally charged for their roles in the once revered investment bank’s demise. Did they know that the firm would not survive even while they raised new 11th hour capital?

Debate continues whether the government had the legal power to prevent the collapse. There are good arguments on both sides of the issue, and it’s hard to say if anyone knows the real answer. If the consequences of the collapse had been fully appreciated, would it still have been allowed to fail?

What is clear is that after September 15th, no other large institutions failed. This may indicate that the government had seen enough. Playing the part of referee in a brutal boxing match, it stopped the action rather than watch any more.

The article correctly notes that appendicitis can be a difficult diagnosis, and that around 16% of appendectomies are done on those who do not have appendicitis. This percentage is consistent with many past studies. The article then suggests that a CT scan should be done, especially if the white cell count is over 10,000. Disregarding the minor factual error (CT scans are not done for the “stomach”, but more precisely, the abdomen and pelvis), the article ignores the role of ultrasound.

We know that CT scans are not harmless tests. The radiation involved in a CT scan is significant, especially in younger patients. Although the question cannot be considered fully settled, there is mounting evidence that CT scans increase the risk of future cancers. As in all situations in medicine, testing decisions have to be weighed in terms of the risks and benefits of each option.

Although not as sensitive or specific as CT scanning, ultrasound does not use radiation. In light of the long-term effects of CT scanning, this makes ultrasound an attractive first test. With a history and exam favorable for appendicitis, a positive or near-positive ultrasound is usually enough to make the decision to operate, especially in the setting of an elevated white count. Adding a CT scan will seldom change this conclusion, but it adds radiation risk and system costs.

In cases where the ultrasound is inconclusive or suggests other pathology, CT may be an appropriate follow-up exam.

There is an informative article on the North Carolina Medical Board’s website concerning “Physician Drift”, or the phenomenon of doctors practicing medicine far outside their areas of residency training. The article highlights many key points including:

-States do not issue specialty specific licenses.
-Doctors frequently must update learning within their specialties to keep up with advancing medical knowledge and procedures.
-More doctors try to develop cash-based services due to changes in medical economics.
-No 21st century doctor can or should be able to practice in every area of medicine.

The concept of physician drift is old news for those in highly competitive medical markets, which tend to be saturated with physicians. Drift occurs towards specialties with a high percentage of cash-paid discretionary procedures; cosmetic dermatology and surgery. I don’t know of any plastic surgeons that have opened cash-only concierge medical practices to do family practice. But there are internal medicine doctors rebranded as “cosmetic surgeons”, performing liposuction and other surgeries.

The public is easily fooled with non-residency training certificates, good-quality marketing and sharp websites. A fancy office decor never hurts either.

In the defense of non-surgeon practitioners, I don’t think many of them ever thought they would have to switch specialties in order to make ends meet. Most nonsurgical residents are not envisioning the day when they will be doing breast augmentations. It’s only when they encounter the realities of 21st century medical practice – market-based overhead faced with arbitrary, non market-based fee schedules – that they realize they need to raise revenue from somewhere. I theorize that with a more transparent and market-based system, physician drift would be a non-issue.

I expand on the NC article by subdividing “drift” into two varieties: upstream drift and downstream drift. Upstream drift is the more dangerous variety, where a lesser-trained doctor tries to take on procedures in which they had no formal residency training. A family practice doctor doing liposuction is one example. Downstream drift is where someone with substantial training takes on out-of-specialty work which is not difficult. A cardiothoracic surgeon doing Botox and facial fillers is not a significant patient-safety issue.

Plastic surgeons seeking to defend their specialty with legislation are sometimes derided for using the patient-safety argument to protect turf. They are trying to do both, because protecting turf also aids patient safety. And plastic surgeons are not above scrutiny, as many have discarded reconstructive practices (or never started them) in favor of better remunerated cosmetic practices.

Concerning patient safety, there are training programs which advertise to non-core physicians, offering weekend training courses in liposuction, breast augmentation, and more. Some were once advertised in official publications of the American College of Surgeons (ask me about that sometime).

Breast augmentation is relatively straightforward, right up to the point where someone puts a hole in the chest cavity – which can happen even by a properly trained plastic surgeon.

Liposuction is relatively straightforward, right up to the point where someone puts a cannula through abdominal organs – which can happen even by a properly trained plastic surgeon.

Physician drift is not likely to change anytime soon. If anything, it will become more prominent, as the move towards outpatient surgery continues. It is far more difficult to “drift” when hospital credentialing boards review physician backgrounds prior to granting clinical privileges.

Drift is not a major item on the healthcare radar-screen, and there are currently bigger issues to be sorted out as the new health-reform act begins to take effect. But the implications for patients are clear: do your homework when researching any cosmetic procedures, and don’t forget to research the doctor as well.